AIM_Benefit Guide_2023 Flipbook PDF - PDF Free Download (2024)

benefits GUIDE

YOUR 2023

JANUARY 1—DECEMBER 31, 2023

Eligibility

You are eligible for benefits if you work 30 or more hours per week. You may also enroll your eligible family members under certain plans you choose for yourself. Eligible family members include: ▪ Your legally married spouse ▪ Your registered domestic partner (RDP) and/or their children, where applicable by state law ▪ Your children who are your natural children, stepchildren, adopted children or children for whom you have legal custody (age restrictions may apply). Disabled children age 26 or older who meet certain criteria may continue on your health coverage.

When Coverage Begins ▪

New Hires: You must complete the enrollment process within 30 days of your date of hire. If you enroll on time, coverage is effective on the first of the month following 30 days from your date of hire. If you fail to enroll on time, you will NOT have benefits coverage (except for company-paid benefits).

Open Enrollment: Changes made during Open Enrollment are effective January 1—December 31, 2023.

Choose Carefully!

Due to IRS regulations, you cannot change your elections until the next annual Open Enrollment period, unless you have a qualified life event during the year. Following are examples of the most common qualified life events: ▪ Marriage or divorce ▪ Birth or adoption of a child ▪ Child reaching the maximum age limit ▪ Death of a spouse, RDP, or child ▪ You lose coverage under your spouse’s/RDP’s plan ▪ You gain access to state coverage under Medicaid or CHIP

Making Changes

To make changes to your benefit elections, you must contact Human Resources within 31 days of the qualified life event (including newborns). Be prepared to show documentation of the event such as a marriage license, birth certificate or a divorce decree. If changes are not submitted on time, you must wait until the next Open Enrollment period to make your election changes.

To enroll online, go to http://agapeim.ease.com Required Information—When you enroll, you will be required to enter a Social Security number (SSN) for all covered dependents. The Affordable Care Act (ACA), otherwise known as health care reform, requires the company to report this information to the IRS each year to show that you and your dependents have coverage. This information will be securely submitted to the IRS and will remain confidential.

Medical We’re proud to offer you a choice of medical plans through California Choice. Kaiser Platinum HMO A

Sutter Platinum HMO B

Sutter Platinum HMO A

Kaiser Gold HMO B

Sutter Gold HMO B

In-Network Only

In-Network Only

In-Network Only

In-Network Only

In-Network Only

$0

$0

$0

$250 / $500

$250 / $500

$3,000 / $6,000

$3,500 / $7,000

$4,500 / $9,000

$7,800 / $15,600

$7,800 / $15,600

$10 / $20 copay

$15 / $30 copay

$20 / $30 copay

$35 / $55 copay

$35 / $55 copay

No charge

No charge

No charge

No charge

No charge

$20 / $40 copay

$15 / $25 copay

$20 / $30 copay

$35 / $55 copay

$35 / $55 copay

$150 copay

$150 copay

$100 copay

$250 copay*

$250 copay*

Chiropractic (20 visits max/year)

$15 copay

Not covered

Not covered

Not covered

Not covered

Ambulance

$150 copay

$100 copay

$150 copay

$250 copay*

$250 copay*

Emergency Room

$200 copay

$100 copay

$150 copay

$250 copay*

$250 copay*

Urgent Care Facility

$10 copay

$15 copay

$20 copay

$35 copay

$35 copay

Inpatient Hospital Stay

$500 copay

$250/day

$250/day

$600/day*

$600/day*

Outpatient Surgery

$300 copay

$125 copay

$125 copay

$335 copay*

$335 copay*

Retail Pharmacy (30-day supply)

$5 / $15 / $15

$5 / $15 / $30

$5 / $20 / $30

$15 / $40 / $40

$15 / $40 / $70

Mail Order (90-day supply)

$10 / $30 / $30

$10 / $30 / $60

$10 / $40 / $60

$30 / $80 / $80

$30 / $80 / $140

Key Medical Benefits

Anthem Gold HMO B

WHA Gold HMO B

WHA Gold HMO C

WHA Gold HMO D

Sutter Silver HMO C

In-Network Only

In-Network Only

In-Network Only

In-Network Only

In-Network Only

$0 / $0

$250 / $500

$1,000 / $2,000

$2,4002 / $4,8002

$2,500 / $5,0002

$6,500 / $13,000

$7,800 / $15,600

$7,800 / $15,600

$4,800 / $9,600

$7,050 / $14,100

$30 / $60 copay

$35 / $55 copay

$40 / $40 copay

$0*

$35 / $50 copay*

No charge

No charge

No charge

No charge

No charge

$15 / $15 copay

$35 / $55 copay

$0 / $40 copau

$0*

$35 / $15 copay*

$250 copay

$250 copay*

$300 copay

$0*

$50 copay*

Key Medical Benefits Deductible (per calendar year) Individual / Family

Out-of-Pocket Maximum (per calendar year) Individual / Family

Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging

Prescription Drugs (Tiers)

Deductible (per calendar year) Individual / Family

Out-of-Pocket Maximum (per calendar year) Individual / Family

Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging Chiropractic (20 visits max/year)

$15 copay

$15 copay

$15 copay

$0*

Not covered

Ambulance

$150 copay

$250 copay*

$0

$0*

25%*

Emergency Room

$325 copay

$250 copay*

$300 copay*

$0*

25%*

Urgent Care Facility

$30 copay

$35 copay

$50 copay

$0*

$35 copay*

Inpatient Hospital Stay

$550 copay

$600/day*

$500/day*

$0*

25%*

Outpatient Surgery

$500 copay

$335 copay*

$500 copay*

$0*

25%*

$10 / $50 / $90

$15 / $40 / $70

$10 / $501 / $751

$0* / $40* / $50*

$20* / $40* / $60*

$0* / $100* / $150*

$40* / $80* / $120*

Prescription Drugs (Tiers) Retail Pharmacy (30-day supply) Mail Order (90-day supply)

$25 / $150 / $270

$38 / $100 / $175

1

$25 / $125 / $188

1

Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. The amount reflected represents the member’s cost after the pharmacy deductible has been met—$500 Individual, $1,000 Family 2. The deductible applies to both Medical & Rx.

Medical Anthem Gold PPO E

Key Medical Benefits

Anthem Silver PPO C

In-Network Only

Out-of-Network1

In-Network Only

Out-of-Network1

$500 / $1,500

$2,000 / $4,000

$1,700 / $3,400

$3,400 / $6,800

$7,700 / $15,400

$15,400 / $30,800

$9,100 / $18,200

$18,200 / $36,400

$30 / $60 copay

50%*

$50 / $95 copay

50%*

Deductible (per calendar year) Individual / Family

Out-of-Pocket Maximum (per calendar year) Individual / Family

Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging Chiropractic

No charge

Not covered

No charge

Not covered

$15 / $15 copay

50%*

$20 / $20 copay

50%*

$100 copay then 20%*

50%*

$100 copay then 40%*

50%*

50%

Not covered

50%

Not covered

Ambulance Emergency Room Urgent Care Facility Inpatient Hospital Stay Outpatient Surgery

20%*

40%*

$250 copay then 20%*

$300 copay then 40% *

$30 copay

50%*

$50 copay

50%*

20%*

50%*

40%*

50%*

$200 copay then 20%*

50%*

$200 copay then 40%*

50%*

$10 / $50 / $90

Not covered

$15 / $702 / $1102

Not covered

Prescription Drugs (Tiers) Retail Pharmacy (30-day supply) Mail Order (90-day supply)

$25 / $150 / $270

Not covered

2

$38 / $210 / $330

2

Not covered

Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount. 2. The amount reflected represents the member’s cost after the pharmacy deductible has been met—$300 Individual, $600 Family

Dental We are proud to offer you a choice of dental plans with SmileSaver through CaliforniaChoice.

Key Dental Benefits Deductible (per calendar year) Individual / Family

SmileSaver 1000 DHMO

SmileSaver 3000 DHMO

In-Network Only

In-Network Only

N/A

N/A

Benefit Maximum (per calendar year; Preventive, Basic and Major services combined) Per Individual

None

None

Covered Services Preventive Services

No charge

No charge

Basic Services

$0 - $95

$9 - $185

Major Services

$50 - $175

$110 - $225

$1,600 Max; See schedule

$1,600 Max; See schedule

Orthodontia (Child only)

Coinsurance percentages shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.

Cost of Benefits Your contributions toward the cost of benefits are automatically deducted from your paycheck before taxes. The amount will depend upon the plan you select and if you choose to cover eligible family members. We will contribute up to $350 per month towards employee medical coverage. Dental Cost

SmileSaver 1000

SmileSaver 3000

Employee (EE) Only

$21.25

$11.92

EE + 1

$35.44

$23.83

EE + 2

$49.31

$34.28

Contact Information Coverage

Carrier

Phone #

Website/Email

Medical

California Choice

(800) 558-8003

www.calchoice.com

Dental

California Choice

(800) 558-8003

www.calchoice.com

Benefits Website Our benefits website http:// www.agapeim.ease.com can be accessed anytime you want additional information on our benefit programs.

Questions? If you have additional questions, you may also contact: HUB Employee Advocate Hotline (877) 838-4779 [emailprotected] Nicole Carillo (916) 784-2800 [emailprotected]

DISCLAIMER: The material in this benefits brochure is for informational purposes only and is neither an offer of coverage or medical or legal advice. It contains only a partial description of plan or program benefits and does not constitute a contract. Please refer to the Summary Plan Description (SPD) for complete plan details. In case of a conflict between your plan documents and this information, the plan documents will always govern. Annual Notices: ERISA and various other state and federal laws require that employers provide disclosure and annual notices to their plan participants. The company will distribute all required notices annually.

AIM_Benefit Guide_2023 Flipbook PDF - PDF Free Download (2024)

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